Arthroscopic Bankart Repair:

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Rachel Rodgers
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1 Arthroscopic Bankart Repair: This protocol is intended to provide Physiotherapists with guidelines for the post-operative management of a patient who has undergone an arthroscopic Bankart repair. This protocol is not a substitute for a Physiotherapist s clinical reasoning during a patient s post-operative healing/progress. Clinical reasoning should be based on individual symptoms, physical signs, progress, and/or the presence of operative complications. If a Physiotherapist requires assistance or guidance at any stage of recovery they should consult with Dr. Rajaratnam s office. Operative Goal: Restore anterior stability of the glenohumeral joint Postoperative Guidelines: - Physiotherapy commencing before 2 weeks post-op - Protect surgical repair o Soft tissue (capsular) tightening - Prevent post-op rehabilitation complications: o Avoid overstretching of anterior capsule (hyper-extension, external rotation) - [Protected] Mobility before strengthening o Gaining ROM too slowly may result in residual stiffness and delayed recovery o Early emphasis on rotational mobility should be performed in resting position of the glenohumeral joint (scapular plane) o Strengthening when range is not available can lead to compensatory movement strategies and poor muscle activation patterns. o N.B. Exercises must not reproduce pain - Return to Work o Determined by Dr. Rajaratnam generally occurs between 3-6 months post-op o Often associated with graduated hours and modified duties - Return to Sport o Determined by Dr. Rajaratnam may occur between 6 to 12 months post-op Dependent on contact vs. non-contact, as well as level of play

2 Arthroscopic Bankart Repair Phase I (Protection): 0-2 weeks Patient Name: D.O.B.: Date: Short Term Goals of Phase I: 1. Education: posture, joint protection, positioning, hygiene, restrictions, ADLs 2. Immobilization with sling (neutral pillow/wedge) to protect surgical procedure 3. Minimize pain and inflammatory response 4. Maintain/restore ROM of uninvolved joints (neck, thorax, elbow, wrist/hand) 5. Improve scapular position Restrictions/Precautions for Phase I: 1. Remain in sling (include sleeping); remove only for showering and ROM exercises 2. Avoid getting incisions wet 3. No driving 4. No ER; avoid shoulder hyper-extension and limit elevation to 120 o 5. No mobilizations/manipulations/traction to GHJ 6. No lifting/pushing/pulling objects with operative shoulder 7. No arm use beyond ROM guidelines/restrictions Management Recommendations for Phase I: 1. Mobility Pendulums (use body sway to move extremity: forward/back, side/side) Neck, thorax, elbow, wrist/hand: general ROM (as needed) 2. Muscle Activation / Awareness Posture awareness/correction Ball squeezes 3. Scar Management - keep incisions clean and dry 4. Modalities - home cryotherapy for ~ 20 min every few hours for pain and inflammatory control Comments:

3 Arthroscopic Bankart Repair Phase II (Mobility): 2-6 weeks Patient Name: D.O.B.: Date: Requirements to progress to Phase II: 1. Follow-up with Dr. Rajaratnam 2. Appropriate healing from surgery by following precautions & immobilization guidelines 3. ROM guidelines met but not exceeded 4. Pain control within allowed ROM Short Term Goals of Phase II: 1. Education: posture, joint protection, positioning, hygiene, restrictions, ADLs 2. Immobilization with sling (neutral pillow/wedge) to protect surgical procedure 3. Minimize pain and inflammatory response 4. Maintain/restore ROM of uninvolved joints (neck, thorax, elbow, wrist/hand) 5. Achieve recommended ROM through gentle and painfree ROM activities 6. Normalize scapular position and mobility (dissociation from GHJ) 7. Improve stability and neuromuscular control of cervical spine (if necessary) Restrictions/Precautions for Phase II: 1. Remain in sling (include sleeping); remove only for showering and ROM exercises 2. ER to neutral 3. Do not stress the anterior GH capsule (i.e., doorway stretch, pec flys, push-ups, etc.) 4. Limit shoulder elevation to 140 o (2-4 weeks); slowly progress to full elevation at 5-6 weeks 5. Avoid hyper-extension (esp. hand behind back) 6. Avoid Active Release Techniques 7. No mobilizations (arthrokinematics)/manipulations/traction to GHJ 8. No lifting/pushing/pulling objects with operative shoulder 9. No arm use beyond ROM guidelines/restrictions Special considerations:

4 Management Recommendations for Phase II: 1. Manual Therapy Passive ROM (passive physiological ROM) within R2 o isolate GHJ (ensure full ROM) before progressing to full elevation Soft tissue massage to shoulder complex (as needed) 2. Mobility - PROM (2-4 weeks) and AAROM (begin at 5 weeks) Pendulums Shoulder: use opposite arm for self PROM (follow ROM guidelines; respect R2) o can progress to wall walking or a stick/cane for AAROM if appropriate timeline and follow ROM restrictions and ensure patient does not push beyond R2 o perform ROM in scapular plane to maximize humeral head/glenoid congruency Neck, thorax, elbow, wrist/hand: general ROM (as needed) 3. Muscle Activation/Awareness Posture awareness/correction Ball squeezes (gentle grip strengthening) Scapular awareness / stabilization o Scapular set to restore optimal position (counteract anterior tilt, depression and downward rotation) o Unilateral elevation/depression/protraction/retraction (commence in sling); progress to scapular clock exercises (as able) Rotator Cuff: o Dynamic relocation training (Magarey & Jones, 2003) 4. Scar management (once incisions have closed) 5. Proprioceptive Awareness OKC and CKC beginner exercises Must fit within ROM guidelines/restrictions 6. Modalities (if no contraindications present) Pain management (e.g., Ice minutes every few hours; TENS / IFC) Cryotherapy Heat 7. Recommended Concomitant Service(s): Massage Therapy (ensure complimentary to PT Rx) Comments:

5 Arthroscopic Bankart Repair Phase III (Neuromuscular Retraining): 6-12 weeks Patient Name: D.O.B.: Date: Requirements to progress to Phase III: 1. Follow-up with Dr. Rajaratnam 2. Compliant with recommendations/restrictions to ensure appropriate healing from surgery 3. ROM guidelines met but not exceeded 4. Pain control within allowed ROM Short Term Goals of Phase III: 1. Education: restrictions 2. Eliminate pain and inflammatory responses 3. Restore full active shoulder mobility within correct movement patterns 4. Restore appropriate capsular extensibility 5. Improve scapular awareness and stability 6. Improve neuromuscular control and endurance of rotator cuff musculature 7. Increase endurance of cervical spine stabilizing musculature (if applicable) Restrictions/Precautions for Phase III: 1. Continue to avoid any pain or apprehension with stretching; do not stretch beyond R2 2. ER to neutral 3. Avoid over-stressing the anterior GH capsule (i.e., doorway stretch, pec flys, push-ups, etc.) 4. Avoid exercises that promote hyper-extension, anterior translation and shoulder impingement 5. No mobilizations (arthrokinematics)/manipulations/traction to GHJ 6. No lifting/pushing/pulling objects with operative shoulder Special considerations:

6 Management Recommendations for Phase III: 1. Manual Therapy Restore full mobility o i.e., Passive Physiological ROM, Muscle Energy, capsular stretching o i.e., Soft tissue release to antagonistic muscle(s) 2. Mobility - AROM Perform AROM in all movement planes of the shoulder with good scapular control and avoidance of compensatory movements o May begin in scapular plane to maximize humeral head/glenoid congruency 3. Muscle Activation/Endurance Scapular stabilization o Restore and challenge optimal mechanics and positioning (facilitate upward rotation) o include OKC & CKC exs; consider requirements for ADLs, sport, work Rotator Cuff: o Progress from dynamic relocation training for HOH positioning to recruitment o As recruitment improves may begin to focus on endurance ~ 8 weeks Exercises must be painfree Start neutral & progress t/o range at limits of good scapular positioning and control (begin in scapular plane) o May begin strength/hypertrophy > 10 weeks as long as exercise is painfree 4. Proprioceptive Awareness OKC and CKC intermediate exercises May include gentle perturbations to GHJ 5. Modalities (if no contraindications present) Pain management (as needed) Neuromuscular Electrical Stimulation 6. Recommended Concomitant Service(s): Massage Therapy (ensure complimentary to PT Rx) Comments:

7 Arthroscopic Bankart Repair Phase IV (Strength and Function): 12 + weeks Patient Name: D.O.B.: Date: Requirements to progress to Phase IV: 1. Follow-up with Dr. Rajaratnam 2. Compliant with recommendations/restrictions to ensure appropriate healing from surgery 3. Full active shoulder mobility within correct movement patterns 4. Improved neuromuscular control and stabilization of scapula 5. Improved neuromuscular control and recruitment of rotator cuff musculature Short Term Goals of Phase IV: 1. Increase strength and endurance of rotator cuff musculature (OKC & CKC) 2. Improve functional strength of shoulder girdle 3. Introduce return to work retraining 4. Introduce sport-specific retraining (approx weeks post-op) Restrictions/Precautions for Phase IV: 1. Slowly increase ER mobility 2. Avoid terminal stretching to restore full ABER mobility Patient must use self control and strengthening/endurance exercises to restore ABER 3. No manipulations to GHJ 4. Light-to-moderate lifting/pushing/pulling objects with operative shoulder 5. Plyometric retraining must be cleared by Dr. Rajaratnam Special considerations:

8 Glossary of Terms: CKC GHJ HOH OKC R2 (end of range) = Closed Kinetic Chain = Glenohumeral joint = Head of humerus = Open Kinetic Chain = end of a joint s available ROM; not necessarily the end of normal physiological limits

Ms. Ruth A. Delaney, MB BCh BAO, MMedSc, MRCS

Ms. Ruth A. Delaney, MB BCh BAO, MMedSc, MRCS Consultant Orthopaedic Surgeon, Shoulder Specialist. +353 1 5262335 ruthdelaney@sportssurgeryclinic.com Modified from the protocol developed at Boston Shoulder